[Second Reprint]

SENATE, No. 47

STATE OF NEW JERSEY

INTRODUCED JANUARY 18, 1996

By Senators LaROSSA and LITTELL

An Act concerning the resolution of certain health care claim payment disputes ²and supplementing various parts of the statutory law².

    Be It Enacted by the Senate and General Assembly of the State of New Jersey:

    1. a. A hospital service corporation shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the corporation ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall provide for direct communication between the provider and the hospital service corporation and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the dispute. ²When the corporation notifies a provider or individual of a billing or payment dispute, the corporation shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the hospital service corporation, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal. ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and hospital service corporation.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A hospital service corporation shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[90] 120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.

    2. a. A medical service corporation shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the corporation ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall provide for direct communication between the provider and the medical service corporation and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the dispute. ²When the corporation notifies a provider or individual of a billing or payment dispute, the corporation shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the medical service corporation, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and medical service corporation.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A medical service corporation shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[90] 120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.

    3. a. A health service corporation shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the corporation ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall provide for direct communication between the provider and the health service corporation and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the dispute. ² When the corporation notifies a provider or individual of a billing or payment dispute, the corporation shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the health service corporation, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and health service corporation.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A health service corporation shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[ 90] 120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.

    4. a. An insurer issuing individual health insurance policies shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the insurer ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall require direct communication between the provider and the health insurer and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the dispute. ² When the insurer notifies a provider or individual of a billing or payment dispute, the insurer shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the insurer, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and insurer.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A health insurer shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[90] 120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.

    5. a. An insurer issuing group health insurance policies shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the insurer ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall require direct communication between the provider and the health insurer and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the dispute. ²When the insurer notifies a provider or individual of a billing or payment dispute, the insurer shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the insurer, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and insurer.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A health insurer shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[90] 120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.

    ²[6. a. A health maintenance organization shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers and the health maintenance organization resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The procedure shall require direct communication between the provider and the health maintenance organization and shall not require any action by the enrollee after initial verification that the enrollee received the services or treatment which are the subject of the dispute.

    ¹The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and health maintenance organization.¹

    The procedure shall include an internal appeal process by which the health maintenance organization, the provider or the enrollee may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    b. A health maintenance organization shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved 90 days after filing if not affirmatively approved or disapproved within that 90 days. During the 90-day review period, the commissioner may request such amendments to the procedure as he deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved 90 days after filing if not affirmatively approved or disapproved within 90 days from the filing date.]²

    ²[¹ 7.] 6.² a. A dental service corporation shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the corporation ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between a health care provider and the corporation, the² procedure shall provide for direct communication between the provider and the dental service corporation and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the disput. ² When the corporation notifies a provider or individual of a billing or payment dispute, the corporation shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the dental service corporation, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

    The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and health maintenance organization.^{1 2}The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A dental service corporation shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90]120² days after filing if not affirmatively approved or disapproved within that ²[90]120² days. During the ²[90] 120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.¹

    ²[¹8.] 7.² a. A dental plan organization shall adopt and, after approval by the Commissioner of Insurance pursuant to subsection b. of this section, implement a procedure which shall be used to resolve billing and payment disputes between health care providers ²or covered individuals² and the organization ²[resulting from lost or incomplete health care claim forms or electronic submissions, or involving a request for additional explanation as to services or treatment rendered by a health care provider. The] . If a dispute is between between a health care provider and the corporation, the² procedure shall provide for direct communication between the provider and the dental plan organization and shall not require any action by the covered individual after initial verification that the covered individual received the services or treatment which are the subject of the disput. ²When the organization notifies a provider or individual of a billing or payment dispute, the organization shall notify the provider or covered individual of the internal appeal process implemented pursuant to this section.²

    The procedure shall include an internal appeal process by which the dental plan organization, the provider or the covered individual may request an independent review of the initial resolution of the dispute by an arbitrator or independent review organization agreed upon by the parties to the appeal.

     The decision of the arbitrator or review organization, as appropriate, shall be binding on the provider and dental plan organization. ²The internal appeal process shall apply only for health benefits contracts issued, delivered, executed or renewed after the approval of the the procedure by the Commissioner of Insurance pursuant to subsection b. of this section.²

    b. A dental plan organization shall, within 120 days of the adoption of regulations by the commissioner pursuant to this act, file its internal dispute resolution procedure with the commissioner. The procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within that ²[90]120² days. During the ²[90]120²-day review period, the commissioner may request such amendments to the procedure as ²[he] the commissioner² deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved ²[90] 120² days after filing if not affirmatively approved or disapproved within ²[90] 120² days from the filing date.¹

    ¹[7.]²[ 9.¹ ] 8.² The Commissioner of Insurance shall promulgate rules pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to effectuate the purposes of this act. ²[¹The regulations shall include procedures for the resolving of disputes between carriers subject to the provisions of this act and covered individuals.¹]²

    ¹[8.]²[10.¹] 9.² This act shall take effect ²[on the 90th day following enactment] immediately².

Provides for resolution of certain billing disputes between insurer and health care provider without involving insured.